Agitated Saline Contrast Echocardiogram In Cardio-Pulmonary Evaluation

Agitated saline contrast echocardiogram (ASC) is a very useful technique to detect various intracardiac and extra cardiac shunts in daily cardiology practice . Conventional 2D and color echocardiogram may not be well effective in ruling out various intracardiac shunts especially with patients having poor echo window. The introduction of agitated saline with bubbles formed during the study can help delineate different right to left shunt physiology commonly like patent foramen ovale (PFO) which is often sought for in evaluation of cases with young stroke . Various other etiologies like atrial septal defects, atrial septal aneurysm, large right to left shunts with eisenmengerisation can also be evaluated with this simple bedside study.

Prevalence of Patent Foramen Ovale in a Cohort of Children With Cryptogenic Ischemic Stroke

ObjectiveTo determine the significance of patent foramen ovale (PFO) in childhood stroke, we compared PFO prevalence, PFO features, and stroke recurrence risk in 25 children with cryptogenic arterial ischemic stroke (AIS), 54 children with AIS from a known etiology, and 209 healthy controls.MethodsWe performed a case-control analysis of a 14-year prospectively enrolled single-center cohort of children with AIS who underwent transthoracic echocardiogram (TTE) and compared them to TTEs of otherwise healthy children evaluated for benign cardiac concerns. Stroke patients aged 29 days to 18 years at stroke ictus with confirmed acute AIS on imaging, availability of complete diagnostic studies of stroke risk factors including TTE images available for central review, and at least one follow-up evaluation after index stroke were included.Presence of PFO and high risk PFO features were assessed by 2 independent, blinded reviewers and compared between groups using Fisher’s exact test. Stroke/TIA recurrence risk was determined using Cox proportional hazards models.ResultsOf 154 children with first-ever AIS, 79 were eligible; 25 had cryptogenic AIS and 54 had a known cause. PFO prevalence was higher in the cryptogenic group (7, 28%) compared to both the known stroke etiology group (3, 5.6%, p = 0.009) and non-stroke controls (24, 11.5%, p = 0.03). There were no significant differences in presence of right-to-left shunt and atrial septal aneurysm. Median follow-up time for entire stroke cohort was 20.9 months. Stroke-free recurrence at 2-years did not differ between children with and without PFO (HR 2.0, 95% CI 0.4-9.3, p = 0.39).ConclusionPFO prevalence was higher in children with cryptogenic stroke compared to AIS patients with known etiology and healthy controls. PFO was not associated with increased recurrence risk. Optimal secondary preventative treatment in children with cryptogenic stroke and PFO remains uncertain and requires further study.Classification of Evidence:This study provides Class III evidence that children with cryptogenic ischemic stroke have an increased frequency of PFO compared to children with ischemic stroke of known etiology and healthy controls.

Concomitant pulmonary embolism and upper limb ischaemia as a first presentation of a patent foramen ovale

A 78-year-old female patient presented to the emergency department with syncope and dyspnoea. The left arm appeared to be cold and radial pulse was not palpable. A CT scan of the chest and left arm with intravenous contrast displayed bilateral central pulmonary embolisms in combination with a left subclavian artery embolism and an atrial septal aneurysm. Transthoracic echocardiography identified a patent foramen ovale with right-to-left shunting confirming the diagnosis of paradoxical embolism. The patient was treated with anticoagulants. In a patient presenting with a combination of a pulmonary embolism and a peripheral arterial embolism, the clinician should consider a right-to-left shunt with paradoxical embolism. In line with this, when diagnosing a peripheral arterial embolism, a central venous origin should be considered. Furthermore, when diagnosing a pulmonary embolism or other forms of venous thromboembolism, the clinician should be aware of signs of a peripheral arterial embolism.

Modified Technique to Control the Eutachian Valve During Transcatheter Closure of Atrial Septal Defect/Patent Foramen Ovale

Objective to describe an approach to perform safe transcatheter closure of Atrial Septal Defect (ASD)/Patent Foramen Ovale (PFO) associated with large redundant Eustachian Valve. Background Transcatheter device closure of ASD/PFO is feasible in a great majority of patients. However, the presence of a huge mobile Eustachian Valve can compromise device placement. Patients and Methods Six patients (3 PFO and 3 ASD patients) with a huge redundant Eustachian valve were included. Two patients had PFO with long tunnel and were closed with Occlutech FigullaFlex II PFO occluders sized 23/25 and 27/30 respectively. The other PFO patient had an associated atrial septal aneurysm (ASA) and was closed with a 25 mm Amplatzer Multi-Fenestrated Septal Occluder “cribriform” device (St. Jude Medical – Abbott Vascular). The three ASDs were closed by regular ASD occluders (2 Flex II ASD Occluders sized 30 and 33 mm and 1 Amplatzer ASD Occluder sized 24 mm). Eustachian valve was successfully held with a steerable ablation catheter to deflect it against the lateral right atrial wall, keeping it away from the inter-atrial septum to prevent its entrapment or interference with the cable, the sheath or the device. Results All ASDs/PFOs have been successfully closed with no complications with free inferior vena cava (IVC) flow, with no residual inter-atrial shunt and the eustachian valve is not interfering with the device. Conclusions Safe percutaneous ASD/PFO closure can be achieved with proper control of a large redundant Eustachian valve.

Atrial fibrillation screening on holter monitoring after percutaneous patent foramen ovale closure: a prospective study

Background An increased risk of new-onset atrial fibrillation (AF) after patent foramen ovale (PFO) closure was observed in randomized trials. However, systematic screening of AF was not performed in these studies. Purpose We aimed to evaluate incidence of AF in patients undergoing percutaneous PFO closure with serial 24-hours ambulatory electrocardiogram (AECG) monitoring during a 6-months follow-up. Methods All consecutive patients undergoing PFO closure for cryptogenic stroke or decompression sickness (DSC) were prospectively included in 2 centers. AF was defined as an irregular rhythm without discernible P waves lasting at least 30 seconds on 24-hours AECG performed at day 0, 1 month and 6-months follow-up. Primary endpoint was incidence of AF within the study period. Secondary endpoints evaluated clinical outcomes (hospitalization for cardiovascular causes, new stroke or bleeding) within 6-months follow-up. Results Between February 2018 and March 2019, a total of 62 patients underwent PFO closure: 59 (95.2%) for cryptogenic stroke and 3 (4.8%) for DSC. In the overall population, 40 were male (64.5%) and the mean age was 48±9.5 years. An atrial septal aneurysm was present in 37 patients (64.9%). The PFO device mean size was 26±5.0 mm. After a mean follow-up of 33.3±12.2 weeks, new-onset AF occurred in 3 patients (4.8%), all within 1-month after closure and paroxysmal. While symptomatic ectopic atrial heart beats occurred in one fourth of patients, all AF episodes asymptomatic. Two patients (3.2%) required oral anticoagulant therapy according to CHA2DS2-VASc score. No adverse outcomes occurred. Age (RR 1.26 [0.98; 1.61] p=0.3), male sex (p=0.6) and device (p=1.0) were not associated with occurrence of AF but all patients with AF were men and received an Amplatzer device. Conclusion Incidence of AF, evaluated with serial systematic 24-hours AECG during a 6-months follow-up after PFO closure, was relatively low (<5%). Always paroxysmal, AF always occurred within one month after the procedure and was not associated with adverse outcomes. FUNDunding Acknowledgement Type of funding sources: None.

Prominent prolapsing Chiari network: presentation and prognosis in paediatric patients

Chiari network is an infrequently visualized web-like structure in the right atrium that is usually thin and small. Rarely, it can be prominent and elongated with protrusion into the right ventricle during diastole and complications have been reported. Thirty-eight patients (median age 2.5 years) with prolapsing Chiari network were identified and associated cardiac abnormalities documented. Echocardiographic right and left heart parameters were measured and compared to normative data. At presentation, the extent of Chiari network prolapse below the tricuspid annulus was 9.1 ± 3.5 mm (mean ± standard deviation), mean pulmonary valve annulus diameter z-value was reduced (-0.91 ± 0.64), and mean aortic valve z-value was enlarged (+0.97 ± 0.87). Fourteen patients exhibited no other cardiac abnormality. Eight were noted to have atrial septal defects, eight demonstrated supraventricular dysrhythmias, six had mild to moderate tricuspid valve regurgitation, and one patient each had an atrial septal aneurysm, severe pulmonic valve stenosis, small perimembranous ventricular septal defect, bicuspid aortic valve, and mild right upper pulmonary vein stenosis. Fourteen patients (37%) were seen in follow-up from 1 to 8.5 years later (median 3.2 years). During that time, the magnitude of prolapse across the tricuspid valve decreased by up to 7 mm (median 2 mm). Interventions were required in three patients, but many associated cardiac abnormalities resolved spontaneously with growth. Thus, the presence of a prolapsing Chiari network has a substantial risk of associated CHDs. However, the extent of Chiari network prolapse gradually decreases and many related abnormalities resolve during growth.

Increased Mobility of the Atrial Septum in Aortic Root Dilation: An Observational Study on Transesophageal Echocardiography

Background: There is a growing interest in the relationship between atrial septal anatomy and cardioembolic stroke. Anecdotal reports suggest that the enlargement of the aortic root could interfere with atrial septal mobility (ASM). We sought to investigate the association between ASM and aortic root dilation.Methods and Findings: From all consecutive clinically requested transesophageal echocardiogram (TEE) studies performed during the study period in a single institution, we were able to review and evaluate the ASM and anteroposterior length, aortic root diameter, and the prevalence of atrial septal aneurysm (ASA) and of patent foramen ovale (PFO) in 336 studies. Additional variables, such as left ventricular ejection fraction, left atrial diameter, diastolic dysfunction, age, sex, weight, height, previous stroke, atrial fibrillation, and TEE indication, were extracted from patient medical records and echocardiographic clinical reports. In 336 patients, we found a mean ASM of 3.4 mm, ranging from 0 to 21 mm; 15% had ASA and 14% had PFO. There was a 1.0 mm increase in ASM for every 10-mm increase in aortic root diameter adjusted for age, sex, weight, height, ejection fraction, and left atrial size (B = 0.1; P = 0.04). Aortic diameter was not associated with a smaller septal length (B = 0.03; P = 0.7).Conclusion: An increased motion of the atrial septum can occur in association with aortic dilation. These findings deserve attention for the relevance of aortic root anatomy in future studies involving atrial septal characteristics and embolic stroke risk.

Importance of direct right-to-left shunt as high-risk patent foramen ovale associated with cryptogenic stroke

Background: Because transcatheter closure of patent foramen ovale (PFO) has become effective for preventing cryptogenic stroke (CS), it is necessary to determine high-risk PFO associated with CS. This study aimed to clarify the importance of direct right-to-left (RL) shunt through the PFO for identifying high-risk PFO. Methods: We analyzed 137 patients with and without CS who were confirmed to have PFO. The timing of RL shunt through the PFO was evaluated by cardiac cycles after right atrium (RA) opacification on saline contrast transesophageal echocardiography. Direct RL shunt was defined as microbubbles crossing the PFO before and at the same time of RA opacification. Results: Cardiac cycles of microbubbles crossing the PFO were shorter in patients with CS than in those without CS (2.0 ± 2.2 vs. 0.5 ± 1.1, P < .01). Direct RL shunt was more frequently observed in patients with CS than in those without CS (77% vs. 29%, P < .01), with a sensitivity of 79% and a specificity of 71% for the association with CS. Multivariate analysis revealed that direct RL shunt was related to atrial septal aneurysm and low-angle PFO. Regarding functional features of PFO, the detection rate of CS was 50% for large RL shunt alone, and was increased to 83% when direct RL shunt was added. Conclusion: Direct RL shunt was associated with CS and had the incremental value in detecting PFO associated with CS for large RL shunt. The timing of RL shunt can be valuable for identifying high-risk PFO.

Fetal Atrial Flutter Associated With Atrial Septal Aneurysm

Objective: To provide evidence that fetal atrial flutter (AF) caused by atrial septal aneurysm (ASA) can be completely cured by delivery. Cases: Three fetuses with ASA complicated by AF in late gestation, including hydrops fetalis in one case, were collected and completely followed up. AF in all cases completely disappeared shortly after birth. New insights gained from this study are as follows: 1) PACs or bigeminy associated with ASA can progressively change to AF. 2) AF associated with ASA can cause hydrops fetalis and intrauterine treatment is needed but delivery is definitive treatment. 3) AF associated with ASA completely resolves after birth. Conclusion: This report may have clinical impact because of providing evidence that 1) In case of AF associated with ASA, the prognosis is much better than other causes and delivery should be strongly considered. 2) Fetuses diagnosed with AF should always be looked for the presence of ASA. 3) PAC/bigeminy related to ASA, different from isolated PAC, needs close follow-up for development of SVT and AF. 4) The fetuses remote from term can benefit from intrauterine treatment to avoid hydrops fetalis, and to prolong gestation for maturity and early delivery is recommended once lung maturity is confirmed.